Provider Demographics
NPI:1669449443
Name:RICHARDSON, MARK DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E MANSION ST
Mailing Address - Street 2:SUITE 1E
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-1559
Mailing Address - Country:US
Mailing Address - Phone:269-781-3938
Mailing Address - Fax:
Practice Address - Street 1:215 E MANSION ST
Practice Address - Street 2:SUITE 1E
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-1559
Practice Address - Country:US
Practice Address - Phone:269-781-3938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301047635207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2895802Medicaid
MIB47858Medicare UPIN